1997-03

ANNUAL MEETING

Keynote, Plenary Lineup Highlights 1997 ISTSS Meeting

The wide-ranging impact of the keynote and plenary speakers at the 1997 ISTSS Annual Meeting in Montreal, Nov. 6­10, is testimony to the growing influence of the Society's Annual Meeting as a forum for dissemination and discussion of critical information in the trauma field. This year's conference theme, "Linking Trauma Studies to the Universe of Science and Practice," resonates particularly with the keynote and plenary sessions, which demonstrate the increasing impact of trauma studies in the realms of psychopathology and health and social services. The following is a summary of these newsworthy presentations.

Keynote Presentations

Edna Foa, PhD, director of the Center for the Treatment and Study of Anxiety at Allegheny University of the Health Sciences, presents the first of two keynote addresses, "The Psychopathology and Treatment ofo PTSD: Comparison with Other Anxiety Disorders." Foa's work delineates the differences between PTSD and other anxiety disorders and places the psychopathology of anxiety disorders within the framework of emotional processing theory. Foa suggests that cognitive behavior therapy corrects the pathology that underlies PTSD and provides data to support this assertion.

Responding to the recent proliferation of lawsuits against dissociative-disorder and trauma therapists, Alan Scheflin, law professor at Santa Clara University Law School, presents the keynote address "Risk Management in Dissociative Disorder and Trauma Therapy." Scheflin points out that before 1990 there were virtually no lawsuits involving "talking cures," whereas there are currently almost 1,000 lawsuits pending against dissociative-disorder and trauma therapists. Scheflin analyzes the major arguments of hundreds of recent cases against therapists in order to give sound practical advice on risk management and malpractice avoidance.

Plenary Sessions

The meeting's plenary sessions present important research and theoretical frameworks for PTSD and other psychopathologies. The conference begins with the opening plenary session "The Traumatic Impact of Crime, Violence and Abuse on Children: Current Challenges," presented by David Fenkelhor, codirector of Family Research Laboratory, University of New Hampshire. This comprehensive look at childhood victimization integrates the patchwork knowledge about public policy, practice and research under Fenkelhor's "Developmental Victimology" approach. Through this model, Finkelhor delineates the commonalities and differences in children's reactions to different types of victimizations.

The meeting's second plenary session aims to elaborate the relationship between adversity and psychopathology. The methodology employed by Bruce Dohrenwend, a Columbia University psychiatry professor, examines both extreme (e.g., disasters, military combat) and usual situations to identify possible risk factors for the onset and course of various types of psychopathologies.

Ronald Kessler, professor of health care policy at Harvard Medical School, presents the final plenary session, "PTSD in a National Survey of the United States: Results and Future Directions." Kessler reviews the prevalence and correlates of PTSD in the National Comorbidity Study. His research finds prevalence to be higher than previous studies and identifies powerful risk factors for PTSD (most stronger predictors than trauma exposure per se).

A post-meeting report will appear in the winter edition of StressPoints.

TREATMENT

Acute Responses to War Trauma in Children and Adolescents: The Lebanon Wars

The Lebanon Wars, which started in 1975, died out in 1990; peace has settled since on all of Lebanon except the Southern and Western areas (W. Bekaa), which have been regularly the arena of military operations. The largest such operation, the "Grapes of Wrath," was launched by Israel in April 1996. The Institute for Development, Research and Applied Care (IDRAC) based in Beirut, mobilized its resources upon the invitation and support of UNICEF, and in partnership with the Lebanese Government, Ministry of Education (MOE), and the support of the Lebanese National Council for Scientific Research, developed a three-fold plan of action to be launched in the South and West Bekaa as soon as a cease-fire was reached Upon conclusion of the cease fire in May 1996, the following plan was implemented: (1) First-line immediate mental health treatment for children and adolescents in the most heavily war ravaged villages (Phase I); (2) assessment of the efficacy of this treatment in a prospective design (Phase II); and (3) assessment of the acute and long term mental health sequelae of the Grapes of Wrath operation on all children and adolescents living in the South and West Bekaa (Phases I&II). The target populations was all six- to 17-year-old children and adolescents enrolled in schools.

First-line immediate treatment. All students of six public schools (N = 2,500) in the villages identified by MOE to be the most exposed were offered a classroom based treatment through their teachers (N = 68). The teachers had received an intensive training from the IDRAC team. The training was preceded by a long debriefing session for the teachers themselves to talk about their own experiences during current and previous episodes of the wars, and by an educational briefing on major psychiatric disorders that follow human-made disasters (depression, anxiety disorders, post traumatic stress disorder).

These were followed by the treatment training, through which we attempted to minimize the impact of traumatic events on children and adolescents, work on natural and expected aftermath symptoms, facilitate the return to a normal life, and prevent the escalation of symptoms toward more exacerbated and severe disorders. Over a period of 12 consecutive school days, teachers held one-hour sessionsto help students express their feelings, correct the wrong assumptions and misconceptions that follow a traumatic event (cognitive restructuring), acknowledge the extent to which students were disturbed, encourage class cohesion in solving specific problems and help students develop coping skills and proper help seeking behavior from the teachers. Group discussions, drawings, role playing and posters were some of the techniques used. Parents were also involved in the treatment through specific home work (about, for example, possible actions to follow in a specific war situation). Teachers were asked to fill a daily "booklet" report prepared by IDRAC that included a detailed description of the sessions and of the students responses and behavior during these sessions. IDRAC's mental health training team supervised the delivery of this first line treatment through 4 long visits with the teachers (each school alone) reviewing their "booklet" reports, discussing the contents with each teacher and recommending the next course of action. Before the start of this treatment, 116 students were randomly selected from the total of 2,500 students and were interviewed (pre-tested) in order to evaluate the effectiveness of the treatment in Phase II (initiated one year later in May 1997).

This treatment was welcomed by teachers and students alike. We were positively surprised to hear the students telling us that this was the first time they had entered into a personal communication with their teachers and indeed felt closer to them. The teachers themselves felt that they had now a "holistic" role and were not "helpless" victims and witnesses of the wars and thus had acquired skills to be more "real" educators. Many told us about a ripple effect in their schools: for the first time in many years, students felt close to each other and helped actively in the daily chores of the school. A detailed analysis of the booklets is underway, in addition to the prospective efficacy of this first line treatment as outlined above.

Assessment of the mental health sequelae of the Grapes of Wrath. The Revised Diagnostic Interview for Children and Adolescents (DICA-R), adapted to Arabic by IDRAC, was administered to a sample (N = 386) representing the total population of children and adolescents students (45,000). The parental version of the DICA-R was also administered to the mothers of the selected students. The interviewers (health counselors from MOE) had received a four-day training program on the Arabic DICA-R along with other instruments, such as the War Events Questionnaire (WEQ). The latter was developed by IDRAC and used in its previous research on the Lebanon Wars and mental health. The WEQ is used to assess the individual level of exposure to specific war events (including the witnessing effect).

This three-fold plan of action was initiated three weeks after the cease-fire. and the Phase I field work was completed in another three weeks.

About 39 percent of the assessed children and adolescents were found to have one or more of the following disorders: depression (12.2%), separation anxiety (15.0%), PTSD (18.1%) and overanxious disorder (19.2%). Diagnosis of these disorders was based on DSM-IIIR criteria. No gender difference was found for the four disorders. Depression, PTSD and overanxious disorder were found to increase with age. Separation anxiety was most prevalent in the 10­12 year age group.

April 1997, one year after the Grapes of Wrath operation, was the date for the initiation of Phase II of the program which evaluated the effectiveness of the First Line Immediate Treatment. The data has been collected and is undergoing analysis.

IDRAC can be reached at fax: 961-1-582560 or e-mail: egkaram@dm.net.lb. Its home page (idrac.org.lb) will be operative in January 1998. *

Plans for the 13th Annual Meeting of the ISTSS are virtually complete as I write this column. The Montreal conference promises to be our biggest and best yet. And with the end of the conference comes the completion of my year as president of the Society. It has been extraordinarily gratifying for me to serve
in this capacity. The Society has matured into a wonderful clinical and research forum for the study
of psychological trauma.

To highlight this I wanted to share with you a recent experience. Intermittently, I am asked to write chapters on PTSD for text books in mental health. Recently I was invited to update a chapter that I had written in 1990 for a text on adult psychopathology. Thinking that revising a chapter would be a relatively easy task, I assigned only a few days for it. I was startled at the realization that the entire chapter needed rewriting. The advances in the field were so profound that many references and almost all conclusions needed to be changed. Things that were speculation seven years ago are now established facts.

These advances are in many different areas: psychological treatments, psychobiological correlates and bases for symptoms, new assessment instruments, identification of risk factors, epidemiological evidence for the pervasiveness of trauma exposure and PTSD, information processing deficits, etc. I would rate the advances made in our understanding of PTSD over this seven years on par with that of any other psychological condition and exceeding most. Yet there are some concerns about our progress.

Most of the major studies on the topic of PTSD received funding support from the National Institute of Mental Health (NIMH) or the Department of Veteran Affairs. For many legitimate reasons (including the "reinvention" of the U.S. federal government), the NIMH is undergoing restructuring in the hope of gaining efficiency. Part of this effort is to subsume the Violence and Traumatic Stress Research Branch under another branch charged with HIV prevention. As well, there is discussion (as there is with many other panels) of dissolving the VTS Review Group. For those of us who were involved in research on PTSD during the 1980s, this is worrisome. Few grants were funded and expertise on PTSD was often lacking on Review Groups to which our grants were submitted. Once, in a VA review section, all 12 grants on PTSD were summarily dismissed because PTSD didn't exist. Could this happen again?

We must remain vigilant to ensure that our work receives ample funding and that progress in the field is maintained. We owe this to the many people who are exposed to traumatic events and who develop PTSD. ISTSS is committed to its role as a stakeholder in the NIMH. The tremendous progress we have made must continue. The new administrative structures must be given every opportunity to work, but they must work. The shockingly high rates of violence and trauma in the United States are ample evidence of the need for substantive scientific work on PTSD.

In my final column as president, I would like to formally thank the members of this year's Executive Committee: Edna Foa as vice president, Sandy Bloom as president-elect, Matt Friedman as immediate past president, John Fairbank as treasurer and Sandy McFarlane as secretary. I would also like to thank all the board members and committee chairs who gave so selflessly of their time to the Society. I would particularly like to thank the members of our United Nations delegation -- Yael Danieli, Ellen Frey-Wouters, Sylvia Mandel and Joyce Braak) -- whose efforts at the UN led to the establishment of a structure for attending to the mental health needs of peoples in distress. This is a truly wonderful accomplishment. They are to be congratulated.

Finally, I'd like to thank you for the honor of being president of ISTSS. It's been a great year for me personally. I have enjoyed working for you and representing you; I look forward to actively being involved in the Society. *

July 9­12, 1998
American Professional Society on the Abuse of Children
Sixth National Colloquium
Hyatt Regency on the River
Chicago, Illinois, U.S.A.
Contact: APSAC, 312/554-0166;
fax, 312/554-0919; e-mail, APSACEduc@aol.com

Editor's Note: With this issue, StressPoints begins a new regular column, "Commentary," which will feature contributions from members of ISTSS on issues relevant to the mission of the Society, particularly matters being newly explored, including those which are controversial. Contributions are invited on any topic likely to be of interest to most members; also welcome are responses to previous columns, including the one from the Editor which follows.

Consider if you will the situation in the United States in the early 1970s: PTSD from rape was unrecognized. Rape victims appearing in an emergency room had a physical exam, perhaps some counseling about venereal disease, and were sent home. About 900,000 people returned to the United States from the Vietnam War with PTSD; few received any diagnosis or treatment. Most who came for treatment at public and private venues were misdiagnosed with another psychiatric disorder. Research into the trauma disorders was largely non-existent.

I was part of an investigative panel convened in Department of Veteran Affairs (VA) headquarters in 1982, triggered by the discovery that, although VA was following Congressional direction by mounting bold new programs for the treatment of PTSD, VA's own Merit Review Board was disapproving funding for most research proposals on PTSD. A review of the reviews that denied PTSD research proposals revealed that they were characterized by unscientific and hostile attitudes toward trauma research and the concept of PTSD. Ventilation of these reviews led to changes in the makeup of the Merit Review Board, and for the first time, substantial VA funding for PTSD research.

Most readers are familiar with the remarkable emergence of recognition and treatment for trauma patients during the past 17 years, including survivors of the full range of traumatic events -- war, sexual abuse, assault, disasters, torture, etc. What is too easily forgotten is that these developments followed years of advocacy by public officials, mental health professionals, patients and others. More recently, the historically cyclical nature of recognition and forgetting of trauma effects over the past 150 years has been further clarified (1,2), demonstrating that "the systematic study of psychological trauma depends on the support of a political movement." (1). Or, to put it another way: There is no trauma field without advocacy.

Advocacy in our field can take many forms, including:

Preparation of amicus curiae briefs in legal cases, which function to educate both sides and the court itself;

Writing informational or educational papers or pamphlets for public audiences, going beyond standard clinical and research publications;

Contributing to enlightenment about political and social issues related to trauma by serving on advisory or consulting committees; and

Establishing standards for using the PTSD diagnosis in the forensic setting.

It is becoming apparent that in the future these activities will be increasingly necessary in order for treatment of and research into trauma disorders to continue. However, not all professionals need to engage in these activities beyond their clinical or research work: doing advocacy is not to the liking of everyone. What is important is for all who work in the field to vigorously support those who do carry out advocacy initiatives, the success of which is vital to all.

The importance of advocacy is increasing because of the likelihood that intense and international backlash phenomena will continue to emerge as counterreactions to worldwide revolutionary changes in understanding, treatment and research concerning trauma. Following the recent exaggerated attacks on childhood abuse victims and their therapists, other backlash manifestations will appear. These may take the form, for example, of attempts to defund PTSD research and treatment services, and other features of irrational denial such as undermining the diagnostic constructs of PTSD and dissociative disorders. We may see tendencies even within the mental health disciplines to diminish our new understanding of the critical role of events in the etiology of PTSD.

The central role of advocacy is further clarified by understanding the sources of irrational denial of trauma and its effects. These include: organizations that stand to lose financially by paying compensation or damages, and perpetrators of assault or abuse and others who want to protect them from exposure or criminal penalties. Irrational denial also stems from ordinary human aversive responses (fear, shame, horror, etc.) to painful realities such as the Holocaust, war and disasters. Denial is also seen in health-care professionals who have been mistakenly dismissive of trauma disorder in the past and who do not have the intellectual humility to acknowledge even to themselves that they have been mistaken.

Last, but not least, mental health clinicians and researchers who work in the trauma field may experience compassion fatigue, which, either because it is not effectively managed or because it is unconscious, leads them to repudiate trauma survivors by returning to a stance of blaming the victim. All clinicians and researchers in the trauma field are potentially subject to vicarious traumatization and compassion fatigue, which may cloud objective thinking about patients or research. (3,4) However, if we understand the universality of compassion fatigue, and that its effects may naturally appear in any of us, we are positioned to avoid its impact on our work. Therapists have much to contribute to this effort, because by training and experience they may be able to achieve a degree of objectivity about irrational beliefs and reactions, not only in patients, but in themselves.

The study of irrational denial and backlash phenomena, both in clinical situations and in formal research, is itself a requirement for the traumatic stress field, if we are to overcome the cycle of history that has tended to bury the field repeatedly in the past.

Seen in relation to the universality of irrational denial and compassion fatigue, advocacy thus becomes something we do not only without (to the professions and the public at large) but also within, that is, within the traumatic stress field and within each of ourselves individually.

UN Commitment to the Status of Mentally Disabled Persons in Developing Countries

By Ellen Frey-Wouters, PhD, LLB, ISTSS Representative to the United Nations

An estimated 300 million people are suffering from mental and neurological disorders and in aggregate these disorders are the single largest cause of lost years of quality of life (WHO, The World Health Report 1996; World Bank, World Development Report, 1993).

Approximately 80 percent of the world's mentally disabled population lives in developing countries. The world confronts a "largely unheralded crisis" in mental, behavioral and social health problems that threatens international political and economic stability and "betrays the humanity" of tens of millions of its victims, according to a 1995 report by Harvard Medical School's Department of Social Medicine. The report declared that "mental health must now be placed on the international agenda," and pointed out that:

"While basic physical health has improved worldwide, mental health has remained stagnant or has deteriorated. An increase in the incidences of clinical depression, schizophrenia, dementia and other forms of chronic illness has accompanied increases in lifespan because more people live to the age of risk. Some of the increase is due to the very improvements in longevity to which health experts and government officials point with so much justifiable pride. Some of it is due to the crushing psychic and social burdens imposed by the urbanization and "modernization" of rural cultures. These same social, political and economic changes have been accompanied by increases in rates of alcoholism, drug abuse and suicide. Rates of violence have increased and will reverse the declines in mortality rates and life expectancy." (1)

In addition, well over 40 million of the world's refugees and internally displaced persons, the victims of civil wars, run a risk of depression, anxiety disorders, PTSD and other forms of mental distress that are consequences of political violence.

Details of the Harvard report were presented on May 15, 1995 to then UN Secretary-General Boutros Boutros-Ghali at a special briefing at UN headquarters. At this conference the Secretary-General stated: "This Report ... reminds us of the great human suffering caused by mental illness ... the international community has risen to many challenges in the past. Now it must do the same [for] mental health ... The challenge is to combine concern for mental health ... with humanitarian assistance and protection efforts. Development policies must ... protect and promote mental health."

In poor countries, persons with mental disabilities are often negatively portrayed, hidden away, abused and stigmatized. They are the last to receive services provided by the community. Society's negative attitudes further exclude them from the mainstream of social, educational and economic life. Because of prejudice or ignorance, they may lack access to essential services. Assistance from the entire international community is needed to put this "silent emergency" to an end.

The Harvard report stresses the interconnectedness of health problems on the one hand, and of psychosocial pathologies, such as violence, alcoholism, abuse of women and children, and underlying social conditions such as war, poverty and discrimination, on the other. It states that the single most important issue is to give priority to mental health around the world. In the words of Secretary-General Boutros Boutros-Ghali: "Medical and social issues which are often viewed separately must be dealt with as a whole ... the priority of mental health must be heightened ... resources must expand ... responsibilities must be recognized more completely."

UN Efforts to Advance the Situation of Mentally Disabled Persons

The UN Charter calls for a "reaffirmation of the dignity and worth of the human person." Article 62 charges ECOSOC with health and related matters. From its early days, the United Nations has sought to advance the status of disabled persons and to improve their lives. As affirmed in related human rights instruments, person with disabilities, physical and mental, are entitled to equal civil, political, social and cultural rights. In 1971, the General Assembly adopted the "Declaration on the Rights of Mentally Retarded Persons." (Resolution 26/2856). This declaration stipulates that mentally retarded persons are accorded the same rights as other human beings.

The attainment of full mental health for all people is recognized in General Assembly Resolution 46/119, "The Protection of Persons with Mental Illness and the Improvement of Mental Health Care" (adopted 12/17/91). The resolution's 25 principles define fundamental freedoms and basic rights of persons with mental illness. Later instruments, such as the Standard Rules on the Equalization of Opportunities for Persons with Disabilities, adopted in 1993, and the Convention on the Rights of the Child, which went into force in 1990, recognize that mentally disabled persons should enjoy a decent life, in conditions that ensure dignity and promote self-reliance. The UN observes the International Day of Disabled Persons every year on December 5 and World Mental Health Day on October 10.

The contribution of the UN High Commissioner for Refugees, UNICEF and the UN Department of Humanitarian Affairs in dealing with traumatized populations has been well documented. (For an excellent discussion, see International Responses to Traumatic Stress, Danieli Y, Rodle, N and Weisaeth L, Eds., Baywood Publishing, 1995).

Recent UN World Conferences reflect the growing awareness that persons with physical and mental disabilities have both special concerns and needs that require serious consideration of the international community. All of these conferences have addressed the situation of people with disabilities and made recommendations to rectify past discriminatory practices as well as protected and promoted their rights to participate in all aspects of the society as citizens of their countries.

The contribution of UN specialized agencies to advance the situation of mentally disabled persons is noteworthy: UNESCO by providing special education, ILO by improving access to the labor market and WHO by providing technical assistance in health and prevention. WHO, especially, performs an important role. Its activities with regard to traumatic stress are dealt with primarily by its Division of Mental Health and the Mental Health Advisors in the WHO Regional Offices.

Major UN Recommendations

UN programs include the following provisions:

A major initiative to upgrade the quality of mental health services in countries of Africa, Asia, the Middle East and Latin America must be undertaken.

The care of the mentally ill should be provided for in national and regional plans and adequate budgetary allocations must be made available.

A cadre of well-trained mental health professionals is necessary to mental health programs in order to design and implement training programs and supervise the care of the chronically mentally ill.

It should be accepted that in most developing countries there is extensive involvement of the patient's family in treatment.

Psychosocial programs should incorporate knowledge and respect for local culture and tradition.

Broad initiatives to control the causes and consequences of violence should be combined with policies that reduce poverty.

(United Nations Development Program, 1996. Human Development Report 1996. Oxford University Press; UNICEF, 1996. The State of the World's Children in 1996. Oxford University Press; WHO, 1995. Bridging the Gaps, Geneva, World Health Organization.

The Role of Nongovernmental Organizations

A major initiative to upgrade the quality of mental health services is only possible by developing an international and regional network of NGOs. Strengthening of partnerships within the United Nations system with NGOs, and civil society through collaboration in research, systematic information exchange and development of common advocacy and public awareness strategies is necessary. The recently established CONGO Committee on Mental Health is of vital importance, because it brings together NGOs from both developed and developing countries. ISTSS played an important role in the establishment of this committee. But the challenges we must face in the mental health field are overwhelming and available resources are limited. ISTSS and its representatives at the UN have an important task before them. *

The National Institute of Mental Health (NIMH) recently formed a working group to prepare an official NIMH report on the psychobiological consequences of torture and extreme trauma, at the request of members of the South African Truth and Reconciliation Commission (TRC). The report will focus on what is known about the acute and enduring psychobiological effects of torture and extreme trauma, including imprisonment, war and combat experiences, mass violence and rape, as well as a discussion of the resultant disability and associated social and economic impact of such trauma. Significant attention will also be given to assessment and treatment issues for survivors and recommendations for future research.

Since early 1996, the South African Truth and Reconciliation Commission has heard testimony from more than 10,000 survivors and perpetrators of torture and violence but has not had the resources to carefully assess the consequences of the torture and trauma that adults and children have experienced in South Africa. Both bureaucratic and practical hurdles have made it difficult for the TRC to draft policy recommendations based largely on the testimony of victims.

The NIMH report stems from converging mental health research, services and human rights interests that came together in April 1997 at an NIMH-cosponsored conference on mental health research and services for survivors of torture. This two-day conference involved leading researchers in the field of trauma and refugee mental health, representatives of treatment centers providing physical and mental health services, survivors of torture and representatives of relevant international human-rights and governmental organizations.

As a result of the Survivors of Torture conference, representatives of the TRC who participated in the conference asked Steven Hyman, MD, director of NIMH, to support the preparation of a scientific document summarizing the psychobiological impact of torture and extreme trauma, including issues of psychiatric diagnosis, disability, functioning, economic cost, treatment and research needs. The TRC representatives felt that such a report would be of great benefit to the treatment, policy and rehabilitation efforts underway in South Africa.

The report is scheduled for completion by the end of 1997 and is intended to be a focused review of the scientific knowledge base in areas of torture and extreme trauma. NIMH and the working group members hope it will be a useful document for individuals and countries in similar situations throughout the world.

By Ingrid Carlier, AZVA, Amsterdam, The Netherlands, and Prof.dr. Berthold Gersons, University of Amsterdam, Amsterdam, The Netherlands

As part of the Dutch longitudinal research project called Critical Incidents in Police Work, an eclectic manual-based protocol for PTSD was developed and evaluated in a randomized pretest-posttest control group design (publication in preparation). The results showed at posttest and at follow-up that treatment had produced significant improvement in PTSD, in resumption of work and in some comorbid conditions. Whether the treatment is effective in other trauma populations needs further investigation. We elaborate here on the specific content of the treatment. (The English version of the treatment protocol can be obtained from our department on request).

We apply this protocol for treatment of PTSD, following Type I psychotrauma in police officers and victims of rape, disaster and accidents. It consists of individual psychotherapy, comprised of 16 weekly 60-minute sessions. It incorporates several intervention techniques also used in the cognitive behavioral protocols of Foa and Resick. Our approach, however, is a more sharply delineated phase-oriented treatment.

In general, the creation of meaning plays a central role in enabling a person to cope adequately with the trauma:

(1) First a theoretical framework is provided within which the patient learns to understand his PTSD symptoms in relation to the trauma (first session with spouse or other significant person).

(2) Then the patient can start to emotionally work through the trauma by means of imaginary guidance. This involves bringing to the surface the hitherto avoided emotions in a way that is gradually and carefully controlled. At this stage writing assignments and memorabilia are helpfulbut interpretations should not yet be given (Sessions 2 through 6)

(3) Now the patient will be open to insightful interpretations and more existential questions concerning his altered view of the world (Sessions 7 through 9, with spouse at Session 9).

(4) In the next stage, the patient consciously considers what he has learned from the trauma and whether this might have led to a degree of personal growth. This entails an explicit pursuit of positive aspects of the traumatic experience (Sessions 10 through 12).

(5) At the final stage, there is the acceptance of the traumatic experience, as is symbolized in a final farewell ritual (Sessions 13 through 16, with spouse at the last session). With this, the patient leaves the trauma behind and takes an active step into the future. *

Readers who have recently published or have seen a new article on a traumatic stress topic can have it listed here by sending a copy to Art Blank, Jr., MD, 8 Carderock Ct., Bethesda, MD 20817. If you have recently authored or seen a relevant book, please send a publisher's brochure or other material describing the book.

The following references were published in 1997, unless otherwise noted.

Blumenfield A, Kluger Y and Rivkind A: Combat trauma life support training versus the original advanced trauma life support course: The impact of enhanced curriculum on final student scores. Military Med. 162(7): 463.

Capital District Psychiatric Center is a 170-bed NYS OMH-operated, JCAHO-accredited, progressive modern facility located contiguous with the Albany Medical College. We are seeking a Staff Psychiatrist for our recently organized 25-bed all-female trauma program. CDPC is a major training center for Albany Medical College psychiatry residents, medical students and other allied professionals. The successful medical candidate would be eligible for faculty appointment with the Albany Medical College. Albany is the capital of New York State, with excellent schools and four seasons of cultural and recreational activities. Please contact Dr. K.S. Krishnappa, M.D., Chief Medical Officer and Associate Vice Chair, Albany Medical College Department of Psychiatry, 75 New Scotland Avenue, Albany, NY 12208. Tel. 518-447-9611, ext. 6808. Fax 518-434-0041. Dr. Krishnappa will be available for interviews at the Montreal ISTSS meeting on November 8 and 9.

Psychologist

National Center for PTSD at Boston, Clinical Research Psychologist. The Behavioral Science Division of the National Center for PTSD has a new opening for a psychologist with research and clinical interests in the area of post-traumatic stress disorder. The National Center is a seven-site consortium funded by the Department of Veteran Affairs to conduct research on PTSD and to provide education about the disorder and its treatment. The Behavioral Science Division is located in the Boston VA Medical Center and currently has a staff of 22, including 10 PhD psychologists and four postdoctoral fellows who are part of an NIMH-funded training program. The Division has a congenial and energetic staff, supported by extensive resources for research, educational and clinical activities. The primary focus of National Center activities is combat-related trauma, but candidates who have experience with and interest in other trauma populations will be favorably considered. Candidates with other specialties (e.g., behavioral medicine, gerontology, personality, lifespan development) who have an interest in applying their expertise to the area of traumatic stress also are welcomed. Requirements for the positions are a PhD and clinical internship from APA-accredited programs, demonstrated research skills, eligibility for professional licensure in Massachusetts and capability for supervising interns who are supported by an APA accredited program in psychology. The successful candidate can expect an academic appointment with Boston University School of Medicine at a level commensurate with experience. Send a curriculum vita with accompanying reprints/preprints, a letter stating professional interests and plans, and three letters of recommendation to Terence M. Keane, PhD, National Center for PTSD (116B-2), Boston VA Medical Center, 150 South Huntington Ave., Boston, MA 02130-4893. Applications will be accepted until all
available positions are filled, but
submission of materials before February 15, 1998 is recommended. The Department of Veteran Affairs is an Equal Opportunity Employer.

UCSF Faculty Position:
Research Psychiatrist or Psychologist

The Department of Psychiatry of the School of Medicine, University of California, San Francisco (UCSF) is seeking a research faculty psychiatrist or psychologist to be based in the Department's program at San Francisco General Hospital (SFGH). SFGH Psychiatry pursues a clinical and research program with strong interest in cross-cultural studies: 38% of SFGH faculty are ethnic minority; 47% are women; 50% of patients are ethnic minority. Appointment will be to an Academic Senate position as Assistant Professor In Residence. The position is available effective July 1, 1998. Desirable candidates will have a track record as productive investigators or will show strong promise to become such investigators, and will possess excellent communication and teaching skills. The incumbent will be expected to develop and implement a program of research on the efficacy or cost-effectiveness of clinical and services interventions for the mental health problems experienced by inner-city poor and ethnically diverse populations like those served by SFGH, collaborate with other faculty in their efforts to develop research programs and teach formal courses and seminars and provide individual student supervision in clinical services research design. Strong promise would be indicated by publication of completed research, funded federal grants, intimate knowledge of the clinical services and target populations typical of urban public hospitals, experience developing innovative services, experience in cross-cultural research and recommendations by research mentors and colleagues. Applications must be received by January 1, 1998. Please send a letter of interest, resume, and names, addresses and telephone numbers of three references to Clifford Attkisson, PhD, Search Committee Chair, c/o Susan Brekhus, Department of Psychiatry -- Room 7M36, San Francisco General Hospital, 1001 Portrero Avenue, San Francisco, CA 94110. UCSF is an Equal Opportunity/Affirmative Action Employer. Women and minorities are strongly encouraged to apply.

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